jueves, noviembre 10, 2011

Triathlete Achilles tendinitis with Rich Plasma Therapy

Platelet Rich Plasma Therapy: One Triathlete’s StoryA triathlete shares her story of overcoming Achilles tendinitisPosted on November 9, 2011 by Jennifer Ward Barber

Amy Javens wrote to us after we published an article in our June/July issue on Platelet Rich Plasma therapy (PRP). A 39-year-old age grouper who has battled chronic Achillies tendinitis since college, Javens decided to try PRP as a last-ditch effort. Her heartfelt letter made us want to publish more of her story. We hope this inspires you all—wherever you are on the health and injury spectrum.

As I velcro my dorsiflexion night splints for another cozy, post-triathlon season night’s sleep, I can’t help but to reflect on and be proud of my 2011 season: overall female wins at Rev 3 Cedar Point (half-iron) and Pittsburgh International Triathlon, 12th amateur at Whirlpool Ironman Steelhead 70.3, and 70.3 Ironman World Championship Qualifier. My biggest achievement was not the trophies or podium finishes, though, it was the fact that I was able to compete in them at all.

Amy with her family at Rev3 Cedar Point

Just a year earlier I had limped away from the Clearwater, Florida field at the the 2010 70.3 Ironman World Championships, my final race of the year, disheartened by severe Achilles tendonitis that had inhibited my training and performance. This chronic pain had haunted me since my collegiate track and field days as a hurdler, sprinter and jumper. It eventually forced me to hang up the track spikes in my junior year. As I began to compete in longer endurance races after having my three daughters it resurfaced, and continued as I started to train for triathlons.

I loved the sport of triathlon too much to just hang it up like my collegiate running career.

Leading up to the 2010 championships, my husband, a physical therapist, and I had treated both my Achilles tendons with about every imaginable traditional rehab modality (iontoforesis, ultrasound, stretch, NSAID, ibuprofen and strengthening). This approach got me through my reduced running training leading up to the goal event, but race day was very painful for me. After the 2010 season, my achilles were so flared that I had to spend the next two days at Universal Studios in a wheelchair being pushed by family members. A comment from my husband post-Worlds that summed up the status of my tendons was, “They are shredded, thickened, and scarred.” I was discouraged.

I had swelling in both Achilles with several nodules in different areas. “Where to go from here,” I asked myself after the race. I thought about just becoming a roadie or an open water swimmer. These sports would allow me to compete and not have to worry about painful flare-ups again, but I loved the sport of triathlon too much to just hang it up like my running career. The sport is one of the things in my life that makes me “me.” I am a multi-tasker, I love the challenge of improving my swim, striving to be a smart and strong cyclist, and a good runner off the bike. I love associating with other triathletes, and I was not going to tolerate and continue with pain that prevented me from reaching my goals. I accepted that I was not going to “just compete.” I wanted to continue to truly COMPETE and TRAIN and be successful at it. I was ready to do anything to guarantee this.

I had heard about a procedure from my coach, Dr. Rick Kattouf (of TeamKattouf), called prolotherapy. His wife, 2011 ITU AG Duathlon World Champion, Gail Kattouf, had successfully tried this procedure over a year ago for her Achilles issues. Prolotherapy is a procedure where a physician injects a dextrose solution (sugar, water) into the injured tendon or ligament. The procedure causes a localized inflammation which then stimulates the tissue to repair itself through an increase of blood supply and flow of nutrients. A sister procedure to prolotherapy is PRP (Platelet Rich Plasma) therapy where the same thing is done with not the dextrose solution but with your own blood, more specifically the platelet rich plasma portion and other growth hormones that naturally occur in your own body. The PRP accelerates the tissue repair and, interestingly enough, signals the body to send stem cells to repair the injured area.

After considering the time with my injury (18 years), exhaustion of traditional modalities, consultation with my husband, and research into prolotherapy versus PRP therapy, I decided to try PRP. Being a Pittsburgh gal, I received my procedure at UPMC (University of Pittsburgh Medical Center) Center for Sports Medicine, one of the leaders in PRP therapy. I figured if great athletes like the Steelers entrusted their sport injury treatment and PRP therapy with UPMC, then I should too!

I made the PRP appointment with a sports medicine doctor (and fellow triathlete) at the center, Dr. Volker Musahl, MD (Assistant Professor of Orthopaedic Surgery and Bioengineering). I had been under his care in the past. My first session was December 1st, 2010, about three weeks past my 70.3 World Championships race. My achilles were still sore to the touch and I could neither heel raise or run going into the first session. I didn’t take any ibuprofens leading into the procedure being careful not to inhibit any of the natural healing processes that were to occur with the injections.

The Procedure

At the first session, blood was carefully drawn from me so not to cause any damage to to platelets. The nurses gently placed my blood in a centrifuge and spun it until it separated the plasma from the other components of the blood. The clear jelly plasma portion, in which my doctor called the “miracle juice” was injected into three different areas of my left and worst tendon. We had marked the most painful portions of the tendon with a marker beforehand so we would inject the PRP exactly in the areas that were in most need of repair. We did not use any local or pain killers for the procedure for the hope of finding these weak tendon areas during the injections. It was a very painful procedure with lots of pressure as the fluid was gently forced into the injured areas.

I had a difficult time sleeping, and woke to shakes and chills from the discomfort.

After the injections I was rescheduled for the second session exactly two weeks later. I was told to continue to avoid NSAIDs, because we wanted my body’s own anti-inflammatory process to occur for the natural healing agents to work. I shuffle-walked out of UPMC and drove home with tears in my eyes as the pain began to increase. I elevated my feet for the next 24 hours as much as I could. I welcomed the pain and tried to visualize my body’s own healing agents at work. Trying to avoid icing my Achilles in hopes of not disrupting the inflammation process, I did succumb to ice one time to alleviate some of the pain. That night, I had a difficult time sleeping, and woke to shakes and chills from the discomfort. Over the next few days the pain subsided but the swelling that was occurring in my tendons inhibited my strength and flexibility. I wore a rehabilitation walking boot on the left foot during the day for approximately a week to reduce the range of motion and promote healing. By the third or fourth night, I was able to start to wear my night splints to stretch my achilles again. By the third day I was able to ride my bike on my computrainer and swim without wall push-offs. After the first week, I was able to begin some light stretching work with bands. By the end of the second week my legs were starting to feel better but were still weak and I could not do a heel raise yet. Running was out of the question and walking was still a shuffling act.

A creative way to keep an icepack in place as she taught Kindergarten: a monkey puppet.

Session Two. December 15th. My husband came to the PRP session and sat next to me and said, “you really love your sport don’t you?” as we repeated the blood draw, the centrifuge procedure, and the multiple PRP injections in both achilles tendons. Again, very painful. I was unable to repeat the rehabilitation boot because both Achilles received the procedure and wearing two boots at the same time to work (as a kindergarten teacher) was definitely out of the question. How was I to do the Hokey Pokey? This time around I found myself handling the pain better and recovering quicker. I was able to wear the dorsiflexion night splints sooner, within two days, and do both standing up stretches and seating band stretches. I began to do strengthening with bands by the end of the first week. But still no consistent heel raises were possible and running was still out of the question.

On December 29th, I received my third and final session. I knew what to expect, which mentally made it more difficult to want to return. But I bit the bullet and took the shots one last time. I knew they were going to continue to be painful for this last session when my doctor gave me permission to curse the pain away. We repeated the procedure and injected both Achilles multiple times again. I rescheduled a follow-up in six week and shuffled out of the center.

I was on my Computrainer the next day, introduced the night splints within a few days, shuffle-walked for about a week, and was back to pushing off the pool wall in my swims by the end of the week. My recovery seemed to be happening even quicker than the preceding sessions which encouraged me to become more aggressive with my stretches and strengthening work.

Rehabilitation

I continued to progress with the stretching and strengthening from non weight bearing to weight bearing exercises for the next month and from low to greater resistance. I implemented eccentric strengthening, and incorporated aquatic therapy to help transition to sport-specific movements such as running in shallow water and plyometric exercises. How the Achilles felt on a daily basis determined how quickly my husband and I could progress with the stretching and strengthening. In a nutshell, we wanted the new growth in the tendons to have the best chance at developing into strong and pliable tendons again. I understood once damaged, tendon fibers will never be the same as the original, but I had confidence that the fibers I was going to develop after all of this would be the best that we could control.

About six weeks after the last PRP session, I began walk/run progressions on treadmill prescribed to me by my coach and gradually increased their duration and frequency. The determining criteria for exercise progression was based upon activity tolerance (proper completion of a set volume with minimal to no symptoms). I continued with this well into my season to maximize my efficiency with reduced stress to the legs. After two months I incorporated land plyometric movements that progressed in intensity, focusing on the Achilles and calf muscles.

Heel raises are an important part of rehabilitation

We restructured my gait and foot strike. A problem is always a problem unless fixed. And that is exact what we tried to do. We analyzed my gait and noticed that my stride cadence was slow and my foot strike needed to move towards more of a forefoot strike. On my treadmill, I focused on a 180-plus hits per minute stride cadence and forefoot striking. I synced my stride strikes with the exact 180 beats to some of the popular songs on my iPod and played them over and over again. Did I tell you that I really like the song, “I Roll Up” by Wiz Kalifa? It is exactly 180 beats per minute and Queens’ “Fat Bottom Girls” is too. The increased cadence and forefoot strike eased the stress on the achilles and surprisingly became one of the contributing factors that made me a faster runner off the bike later in the season.

We also used myofascial release and other soft tissue techniques intermittently as toleranted during the months after the PRP injections. Our theory was to “realign” the fibers and increase flexibility during these healing months. It was amazing to feel the nodules substantially reduce in size over time.

I had heard a comment from someone about PRP therapy that went something like this, “you are better at throwing Fruity Pebbles on an injury than using PRP therapy.” I had to laugh. What I believe is the key to successful PRP therapy is not the healing agents alone in the procedure, but the synchronizing of all avenues to better health and healing. Basically, a holistic and balanced approach. To just use PRP without holistic intervention and proper rehab, biomechanical intervention, and soft tissue release techniques would be like wasting a whole bowl of Fruity Pebbles, only more expensive. And who would want to do that?

I continue to maintain my Achilles by wearing night splints daily, doing progressive strengthening and stretching exercises specifically for my Achilles, and getting massage work with a roller or a therapist. I also continue to check my cadence and foot strike to make sure I’m not reverting back to my old ways. I believe in smart training and not over-training. I am in constant communication with my physical therapist (my husband), my coach, and keep my doctor up to date on my progress. Successful PRP therapy is a multifaceted approach and if approached this way, it will be succcessful.

Amy at the Steelhead 70.3 finish line

I also believe that there is a mental component that comes with success with PRP. Two traits that an athlete must demand of him or herself is patience and trust. I was patient by taking 12 weeks off of running, trusting that the time would let my body heal and would be well worth it. I trusted what others had to tell me that they indeed knew a lot more than me about rehabbing and training. I trusted my husband to write the perfect physical therapy program. I trusted my coach that walk/runs were indeed the right way to train and that the funny looking shoes he had me buy for aqua training were going to be a great investment. And most importantly, I trusted myself that i would return back and supersede my pre-PRP run, but without the pain.

It all ended well. I knew I had come full circle with my comeback when I won overall female at the Pittsburgh International Triathlon, in the same city that just seven months earlier I was shuffling out of in painful tears from the PRP. As I ran towards the finish line by the Roberto Clemente Bridge in this race, I had a smile across my face from the joy of finally running pain-free and appreciation and understanding of how amazing and powerful our own body’s natural healing properties really are.

One month later, I had the same smile on my face as I finished Steelhead 70.3 with a perfectly-paced 7:06 pace for my 13.1 run, again, pain-free. I had indeed came a long way in a mere eight months post PRP, and am looking forward to a great 2012 season.

Information and quotes:

“In our experience, success with PRP lies in the communication between doctor, physical therapist, athlete and coach. Approaching the recovery process in a sequential pattern based upon physiological healing timelines and graded loading of the structure and associated areas helped to insure optimal outcome from the PRP injections.”

“When I first met Amy (at the finish of the 2010 Pittsburgh Triathlon), I had my doubts curing her bilateral chronic Achilles tendinitis by treating her with PRP. I disclosed my reservations to her. But being the competitive athlete she is, she convinced me she would make it work. She did. I contribute this largely to a smart and dedicated approach that Amy took following the injections. She was immobilized for 4 weeks, followed by a long and vigorous course of rehabilitation, before returning to running 5 months later.

“I would like to refer the interested reader to a very good article on the topic of PRP injections by Gina Kolata in the New York Times, September 5, 2011. “The Athlete’s Pain: As Sports Medicine Surges, Hope and Hype Outpace Proven Treatments.”)

- Volker Musahl, MD, Assistant Professor of Orthopaedic Surgery, Division of Sports Medicine, University of Pittsburgh School of Medicine

“Following Amy having PRP on both Achilles, the right balance of swim, bike, run, weight training and rest was critical. I was very exact in her training volume and intensity in order to continue to facilitate recovery of both Achilles and at the same time, continue to improve her fitness. It was this attention to detail combined with Amy’s patience and stic-to-it-iveness that led Amy to her most successful triathlon season.”